REACH (Reversing the Epidemic in Africa with Choices in HIV prevention, or MTN-034, is a study that seeks to understand the HIV prevention needs and preferences of adolescent girls and young women in Africa. Specifically, the study will evaluate how adolescent girls and young women use the monthly dapivirine vaginal ring and Truvada® as daily pre-exposure prophylaxis (PrEP), and their preferences for either or both approaches. REACH will also collect information on the safety of these approaches.
REACH will enroll 300 young women and girls – at least 100 girls ages 16-17 and 200 young women ages 18-21 – at five MTN-affiliated sites in Kenya, South Africa, Uganda and Zimbabwe. The study enrolled its first participant in February 2019. REACH is expected to take about three years to conduct, with results anticipated in late 2022 or early 2023.
The study is funded by the National Institute of Allergy and Infectious Diseases (NIAID); the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and National Institute of Mental Health, all components of the U.S. National Institutes of Health.
How is REACH designed?
REACH is a type of clinical trial called an open-label study in which all participants use an active product. In REACH, there are two products: the dapivirine vaginal ring, which is used for a month at a time, and an oral tablet called Truvada taken daily, a regimen often referred to as PrEP.
All participants will use each product for six months. Random assignment will determine whether PrEP is used for the first six months and then the ring for the following six months, or the ring first and then PrEP. After experiencing both approaches, participants will have a choice of using either the ring or PrEP – or neither – for an additional six months.
To evaluate the safety of each approach, researchers will conduct medical exams and do laboratory tests of blood, urine and vaginal fluid. To evaluate adherence to and acceptability of PrEP and the vaginal ring, participants will answer questions about their use and experience with each product, both on a computer and in face-to-face conversations with site staff. In-depth interviews and focus group discussions will also help understand what motivates or is challenging about using each product.
Why is a study like REACH needed?
No one HIV prevention method will suit everyone, nor suit everyone at all times. As with contraception, the more HIV prevention options available to women, the more likely one will and can be used.
Both PrEP and the ring must be used consistently and regularly to be effective – daily for oral PrEP, and monthly for the ring. Daily pill taking (PrEP) was challenging for young women in clinical trials of PrEP. And, while the monthly ring helped protect against HIV among women older than 21 in ASPIRE, it was not effective among those 18-21, who used the ring least regularly. Similar results were seen among 18- to 21-year-old women in The Ring Study. Researchers need to understand the challenges young women face in using these products, so strategies can be identified that can help.
Truvada as daily PrEP is approved in several countries for ages 18 and older, although the World Health Organization recommends it for anyone at significant risk. In some countries, such as Kenya, rollout includes those younger than 18. The U.S. Food and Drug Administration (FDA) recently expanded approval of Truvada as PrEP for adolescents – technically, for people weighing at least 35 kgs, a decision based on the ATN 113 study in young men who have sex with men in the United States. Though the FDA decision is very encouraging, African regulators will likely need more data about PrEP safety in young African women. Results of a study, called HPTN 082, expected later this year, will shed additional light about PrEP use among girls ages 16-25 in South Africa and Zimbabwe. To date, there is no safety data on the ring in younger African women. The MTN has already completed a safety study of the dapivirine ring in the United States that enrolled 96 girls between the ages of 15-17. Results of this study, referred to as MTN-023 /IPM 030, were reported in 2017 and found the ring was acceptable and well-tolerated. Adherence to ring use was also high.
REACH will add to this data by contributing important information about both PrEP and the dapivirine ring in African girls.
What exactly is the dapivirine ring?
The dapivirine ring is similar to vaginal rings commonly used for contraception except that it contains an ARV drug, dapivirine, instead. Dapivirine belongs to a class of ARVs called non- nucleoside reverse transcriptase inhibitors (NNRTIs) that prevent HIV from making copies of itself. The ring, which is made of a flexible material, sits high inside the vagina, where it slowly releases the drug over the course of the one month the ring is worn. Women can insert and replace the ring themselves.
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Click here to watch a short video about REACH. Additional information about REACH can also be found at https://mtnstopshiv.org/reach-study and http://www.mtnstopshiv.org/news/studies/mtn034. To learn more about the dapivirine ring go to http://www.ipmglobal.org/.